<?include ("bloqueDeSeguridad.php");?>

<html >
<head>

  	<link type="text/css" rel="stylesheet" href="dhtmlgoodies_calendar/dhtmlgoodies_calendar.css?random=20051112" media="screen"></LINK>
  <SCRIPT type="text/javascript" src="dhtmlgoodies_calendar/dhtmlgoodies_calendar.js?random=20060118"></script>
 <script> 
    var val_nom = /^([a-z]|[A-Z]|á|é|í|ó|ú|ñ|ü|\s|\.|-)+$/			//letras, '.' y '-' o vacio
	var val_ape = /^([a-z]|[A-Z]|á|é|í|ó|ú|ñ|ü|\s|\.|-)+$/			//letras, '.' y '-' o vacio
	var val_mail = /^(.+\@.+\..+)$/                                //direccion de correo electronico
	var val_dir = /^([a-z]|[A-Z]|#|[0-9]|á|é|í|ó|ú|ñ|ü|\s|\.|-)+$/			//letras, numeros, '#' '.' y '-' o vacio 
 
  function validarEntero(valor){ 
      //intento convertir a entero. 
     //si era un entero no le afecta, si no lo era lo intenta convertir 
     valor = parseInt(valor) 

      //Compruebo si es un valor numérico 
      if (isNaN(valor)) { 
            //entonces (no es numero) devuelvo el valor cadena vacia 
            return "" 
      }else{ 
            //En caso contrario (Si era un número) devuelvo el valor 
            return valor 
      } 
} 

function valida_registrar(){
    //valido la cedula. el valor no puede ser negativo
	cedula = document.registrar.cedula.value
	cedula = validarEntero(cedula)
	document.registrar.cedula.value=cedula
	if (cedula==""){
		alert("Tiene que introducir un número entero en la cedula.")
		document.registrar.cedula.focus()
		return 0;
	}else{
		if (cedula<0){
			alert("El numero debe ser positivo")
			document.registrar.cedula.focus()
			return 0;
		}
	}
	
	
	//valido el primer nombre
	if (document.registrar.primer_nombre.value.length==0){
		alert("Tiene que escribir el nombre")
		document.registrar.primer_nombre.focus()
		return 0;
	}
	if(!val_nom.test(document.primer_nombre.value)) { 
		alert('Contenido del campo primer nombre no es válido.')
		document.registrar.primer_nombre.focus()
		return 0;
	} 
	
	
		//valido el segundo nombre
	if(!val_nom.test(document.segundo_nombre.value)) { 
		alert('Contenido del campo segundo nombre no es válido.')
		document.registrar.segundo_nombre.focus()
		return 0;
	} 
		
		
		// Validamos la fecha de nacimiento
	if (document.registrar.fecha_nacimiento.value.length==0){
		alert("Tiene que escribir la Fecha de nacimiento ")
		document.registrar.fecha_nacimiento.focus()
		return 0;
	}
		
		
		//valido el primer apellido
	if (document.registrar.apellido.value.length==0){
		alert("Tiene que escribir el apellido")
		document.registrar.apellido.focus()
		return 0;
	}
		if(!val_ape.test(document.registrar.apellido.value)) { 
		alert('Contenido del campo Apellido no es válido.')
		document.registrar.apellido.focus()
		return 0;
	}
	
			//valido el segundo apellido
	if (document.registrar.segundo_apellido.value.length==0){
		alert("Tiene que escribir el segundo apellido apellido")
		document.registrar.segundo_apellido.focus()
		return 0;
	}
		if(!val_ape.test(document.registrar.segundo_apellido.value)) { 
		alert('Contenido del campo Segundo Apellido no es válido.')
		document.registrar.segundo_apellido.focus()
		return 0;
	}
		
	
			//valido la eps
	if (document.registrar.eps.value.length==0){
		alert("Tiene que escribir la EPS ")
		document.registrar.eps.focus()
		return 0;
	}
			if(!val_dir.test(document.registrar.eps.value)) { 
		alert('Contenido del campo EPS no es válido.')
		document.registrar.eps.focus()
		return 0;
	}
	
	
			// Validamos la fecha de recepcion
	if (document.registrar.fecha_recepcion.value.length==0){
		alert("Tiene que escribir la Fecha de recepcion ")
		document.registrar.fecha_recepcion.focus()
		return 0;
	}
	
			// Validamos la fecha de ingreso laboral
	if (document.registrar.fecha_ingreso_laboral.value.length==0){
		alert("Tiene que escribir la Fecha de ingreso laboral ")
		document.registrar.fecha_ingreso_laboral.focus()
		return 0;
	}
	
	
	
				//valido la arp
	if (document.registrar.arp.value.length==0){
		alert("Tiene que escribir la ARP ")
		document.registrar.arp.focus()
		return 0;
	}
			if(!val_dir.test(document.registrar.arp.value)) { 
		alert('Contenido del campo ARP no es válido.')
		document.registrar.arp.focus()
		return 0;
	}
	
	
				//valido la empresa cliente
	if (document.registrar.empresa_cliente.value.length==0){
		alert("Tiene que escribir la empresa cliente ")
		document.registrar.empresa_cliente.focus()
		return 0;
	}
			if(!val_dir.test(document.registrar.empresa_cliente.value)) { 
		alert('Contenido del campo empresa cliente no es válido.')
		document.registrar.empresa_cliente.focus()
		return 0;
	}
	
	
					//valido la empresa usuaria
	if (document.registrar.empresa_usuaria.value.length==0){
		alert("Tiene que escribir la empresa usuaria ")
		document.registrar.empresa_usuaria.focus()
		return 0;
	}
			if(!val_dir.test(document.registrar.empresa_usuaria.value)) { 
		alert('Contenido del campo empresa usuaria no es válido.')
		document.registrar.empresa_usuaria.focus()
		return 0;
	}
	
			//valido natural de
	if (document.registrar.natural_de.value.length==0){
		alert("Tiene que escribir de donde es natural")
		document.registrar.natural_de.focus()
		return 0;
	}
	if(!val_nom.test(document.registrar.natural_de.value)) { 
		alert('Contenido del campo natural_de no es válido.')
		document.registrar.natural_de.focus()
		return 0;
	}
	
			//valido la direccion
	if (document.registrar.direccion.value.length==0){
		alert("Tiene que escribir la Direccion ")
		document.registrar.direccion.focus()
		return 0;
	}
			if(!val_dir.test(document.registrar.direccion.value)) { 
		alert('Contenido del campo Direccion no es válido.')
		document.registrar.direccion.focus()
		return 0;
	}


//valido telefono
	telefono = document.registrar.telefono.value
	telefono = validarEntero(telefono)
	document.registrar.telefono.value=telefono
	if (telefono==""){
		alert("Tiene que introducir un número de telefono.")
		document.registrar.telefono.focus()
		return 0;
	}
	 if (telefono<0){
			alert("El numero debe ser positivo")
			document.registrar.telefono.focus()
			return 0;
	 }
		

	

	//valido la profesion
	if (document.registrar.profesion.value.length==0){
		alert("Tiene que escribir la profesion")
		document.registrar.profesion.focus()
		return 0;
	}
	if(!val_nom.test(document.profesion.value)) { 
		alert('Contenido del campo profesion no es válido.')
		document.registrar.profesion.focus()
		return 0;
	} 



	//valido el cargo a desempeñar
	if (document.registrar.cargo_desempeñar.value.length==0){
		alert("Tiene que escribir el cargo a desempeñar")
		document.registrar.cargo_desempeñar.focus()
		return 0;
	}
	if(!val_nom.test(document.cargo_desempeñar.value)) { 
		alert('Contenido del campo cargo desempeñar no es válido.')
		document.registrar.cargo_desempeñar.focus()
		return 0;
	} 


			//valido el area departamento
	if (document.registrar.area_departamento.length==0){
		alert("Tiene que escribir el area o departamento ")
		document.registrar.area_departamento.focus()
		return 0;
	}
			if(!val_dir.test(document.registrar.area_departamento.value)) { 
		alert('Contenido del campo area departamento no es válido.')
		document.registrar.area_departamento.focus()
		return 0;
	}


// valido el costo
     valor = document.getElementById(costo).value;
      if( isNaN(valor) ) {
        return false;
       }
	   if (costo<0){
			alert("El numero debe ser positivo")
			document.registrar.costo.focus()
			return 0;
		}




}




</script>
  
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<title>HSEQ Nuevo Paciente</title>
    <style type="text/css">
<!--
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	color: #FFFFFF;
	font-style: italic;
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    </style>
</head>
<body>
<div id="main">
  <div id="header">
    <div align="center" class="nomt" id="div2">
      <h1 class="style13">Health Safety </h1>
      <h1 class="style13">Environment Quality </h1>
    </div>
    <h1 id="logo">&nbsp;</h1>
  </div>
  <hr class="noscreen" />
	 <hr class="noscreen" />
  <div id="cols">
    <div id="cols-in" class="box">
      <!-- /content -->
<hr class="noscreen" />

            <p align="right">
              <!-- Aside -->
              <!-- /aside -->
              <!-- /cols-in -->
            </p>
            <div id="content">
              <div class="in">
                <p id="breadcrumbs">&nbsp;</p>
              </div>
              <h2 class="title-01">Examen - Resultados </h2>
              <div class="in">
                <div class="box"></div>
                <div class="cols5050 box">
                  
				  <FORM ACTION="insertar_pacientes.php" method="post" name="registrar" 	id="registrar" onSubmit="return valida_registrar(this);">
                    <div align="left">
                      <table width="788" height="2867" bordercolor="#0099FF" bgcolor="#FFFFFF">
                        <tr>
                          <td height="59" colspan="13"><div align="center"><strong><u>FACTORES O AGENTES DE RIESGO PRESENTES EN LOS CARGOS DESEMPEÑADOS (ACTUAL Y ANTERIORES) </u></strong></div></td>
                          <td height="59">&nbsp;</td>
                          <td height="59">&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="69" colspan="15">&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"><u>SEGURIDAD</u></div></td>
                          <td height="29" colspan="6"><div align="left"></div></td>
                          <td><div align="center">E1</div></td>
                          <td><div align="center">E2</div></td>
                          <td><div align="center">E3
                            </div>                            <label></label></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4" rowspan="8"><div align="center"></div>                            <div align="center"></div></td>
                          <td height="42" colspan="6"><div align="left">ELECTRICOS</div></td>
                          <td width="18"><div align="center">
                            <input type="checkbox" name="e1_electricos" value="checkbox">
                          </div></td>
                          <td width="18"><div align="center">
                            <input type="checkbox" name="e2_electricos" value="checkbox">
                          </div></td>
                          <td width="22"><div align="center">
                            <input type="checkbox" name="e3_electricos" value="checkbox">
                          </div></td>
                          <td width="155">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="45" colspan="6"><div align="left">INCENDIO</div></td>
                          <td width="18"><div align="center">
                            <input type="checkbox" name="e1_incendio" value="checkbox">
                          </div></td>
                          <td width="18"><div align="center">
                            <input type="checkbox" name="e2_incendio" value="checkbox">
                          </div></td>
                          <td width="22"><div align="center">
                            <input type="checkbox" name="e3_incendio" value="checkbox">
                          </div></td>
                          <td width="155">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="43" colspan="6"><div align="left">EXPLOCIÓN</div></td>
                          <td width="18"><div align="center">
                            <input type="checkbox" name="e1_explocion" value="checkbox">
                          </div></td>
                          <td width="18"><div align="center">
                            <input type="checkbox" name="e2_explocion" value="checkbox">
                          </div></td>
                          <td width="22"><div align="center">
                            <input type="checkbox" name="e3_explocion" value="checkbox">
                          </div></td>
                          <td width="155">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="37" colspan="6"><div align="left">MECÁNICOS</div></td>
                          <td width="18"><div align="center">
                            <input type="checkbox" name="e1_mecanicos" value="checkbox">
                          </div></td>
                          <td width="18"><div align="center">
                            <input type="checkbox" name="e2_mecanicos" value="checkbox">
                          </div></td>
                          <td width="22"><div align="center">
                            <input type="checkbox" name="e3_mecanicos" value="checkbox">
                          </div></td>
                          <td width="155">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="43" colspan="6"><div align="left">LOCATIVOS</div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e1_locativos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e2_locativos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e3_locativos" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="38" colspan="6"><div align="left">DESPLAZAMIENTO</div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e1_desplazamiento" value="checkbox">
                          </div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e2_desplazamiento" value="checkbox">
                          </div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e3_desplazamiento" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="37" colspan="6"><div align="left">ORDEN PUBLICO </div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e1_orden_publico" value="checkbox">
                          </div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e2_orden_publico" value="checkbox">
                          </div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e3_orden_publico" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="42" colspan="6"><div align="left">FENOMENOS NATURALES </div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e1_fenomenos_naturales" value="checkbox">
                          </div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e2_fenomenos_naturales" value="checkbox">
                          </div></td>
                          <td><div align="center">
                            <input type="checkbox" name="e3_fenomenos_naturales" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="27" colspan="6"><div align="left"></div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"><u>PSICOLABORALES</u></div></td>
                          <td height="18" colspan="6"><div align="left"></div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="43" colspan="6"><div align="left">CONTENIDO DE LA TAREA </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_contenido_de_la_tarea" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_contenido_de_la_tarea" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_contenido_de_la_tarea" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="36" colspan="6"><div align="left">ORGANIZACION DEL TIEMPO </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_organizacion_del_tiempo" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_organizacion_del_tiempo" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_organizacion_del_tiempo" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="36" colspan="6"><div align="left">RELACIONES HUMANAS </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_relaciones_humanas" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_relaciones_humanas" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_relaciones_humanas" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="34" colspan="6"><div align="left">GESTÍON</div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_gestion" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_gestion" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_gestion" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="52" colspan="6"><div align="left">AMBIENTE FÍSICO DE TRABAJO </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_ambiente_fisico_de_trabajo" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_ambiente_fisico_de_trabajo" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_ambiente_fisico_de_trabajo" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td width="11">&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"><u>BIOLÓGICOS</u></div></td>
                          <td height="25" colspan="6"><div align="left"></div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="36" colspan="6"><div align="left">MICROORGANISMOS</div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e1_microorganismos" value="checkbox">
                          </div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e2_microorganismos" value="checkbox">
                          </div></td>
                          <td width="22"><div align="center">
                              <input type="checkbox" name="e3_microorganismos" value="checkbox">
                          </div></td>
                          <td width="155">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="27" colspan="6"><div align="left">ANIMALES</div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e1_animales" value="checkbox">
                          </div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e2_animales" value="checkbox">
                          </div></td>
                          <td width="22"><div align="center">
                              <input type="checkbox" name="e3_animales" value="checkbox">
                          </div></td>
                          <td width="155">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="29" colspan="6"><div align="left">VEGETALES</div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e1_vegetales" value="checkbox">
                          </div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e2_vegetales" value="checkbox">
                          </div></td>
                          <td width="22"><div align="center">
                              <input type="checkbox" name="e3_vegetales" value="checkbox">
                          </div></td>
                          <td width="155">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"><u>ERGONÓMICOS</u></div></td>
                          <td height="52" colspan="6"><div align="left"></div></td>
                          <td width="18">&nbsp;</td>
                          <td width="18">&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="36" colspan="6"><div align="left">CARGA DINÁMICA </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_carga_dinamica" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_carga_dinamica" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_carga_dinamica" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="28" colspan="6"><div align="left">CARGA ESTÁTICA </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_carga_estatica" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_carga_estatica" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_carga_estatica" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="30" colspan="6"><div align="left">DISEÑO DE PUESTOS </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_disenio_de_puestos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_disenio_de_puestos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_disenio_de_puestos" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="34" colspan="6"><div align="left">MANEJO DE CARGAS </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_manejo_de_cargas" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_manejo_de_cargas" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_manejo_de_cargas" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="27" colspan="6"><div align="left">MOVIMIENTOS REPETITIVOS </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_movimientos_repetitivos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_movimientos_repetitivos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_movimientos_repetitivos" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="31" colspan="6"><div align="left">VIDEOTERMINALES</div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_videoterminales" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_videoterminales" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_videoterminales" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"><u>QUÍMICOS</u></div></td>
                          <td height="27" colspan="6"><div align="left"></div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="30" colspan="6"><div align="left">GASES</div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_gases" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_gases" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_gases" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="24" colspan="6"><div align="left">HUMOS</div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_humos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_humos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_humos" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="30" colspan="6"><div align="left">POLVOS</div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_polvos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_polvos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_polvos" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="29" colspan="6"><div align="left">LÍQUIDOS</div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_liquidos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_liquidos" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_liquidos" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="22" colspan="6"><div align="left">VAPORES</div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_vapores" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_vapores" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_vapores" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="25" colspan="6"><div align="left">FIBRAS</div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_fibras" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_fibras" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_fibras" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"><u>FÍSICOS</u></div></td>
                          <td height="18" colspan="6"><div align="left"></div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="26" colspan="6"><div align="left">ILUMINACIÓN</div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e1_iluminacion" value="checkbox">
                          </div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e2_iluminacion" value="checkbox">
                          </div></td>
                          <td width="22"><div align="center">
                              <input type="checkbox" name="e3_iluminacion" value="checkbox">
                          </div></td>
                          <td width="155">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="28" colspan="6"><div align="left">RADIACIONES IONIZANTES </div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e1_radiaciones_ionizantes" value="checkbox">
                          </div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e2_radiaciones_ionizantes" value="checkbox">
                          </div></td>
                          <td width="22"><div align="center">
                              <input type="checkbox" name="e3_radiaciones_ionizantes" value="checkbox">
                          </div></td>
                          <td width="155">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="42" colspan="6"><div align="left">RADIACIONES NO IONIZANTES </div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e1_radiaciones-no_ionizantes" value="checkbox">
                          </div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e2_radiaciones-no_ionizantes" value="checkbox">
                          </div></td>
                          <td width="22"><div align="center">
                              <input type="checkbox" name="e3_radiaciones-no_ionizantes" value="checkbox">
                          </div></td>
                          <td width="155">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="29" colspan="6"><div align="left">RUIDO</div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e1_ruido" value="checkbox">
                          </div></td>
                          <td width="18"><div align="center">
                              <input type="checkbox" name="e2_ruido" value="checkbox">
                          </div></td>
                          <td width="22"><div align="center">
                              <input type="checkbox" name="e3_ruido" value="checkbox">
                          </div></td>
                          <td width="155">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="34" colspan="6"><div align="left">TEMPERATURA ALTA </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_temperatura_alta" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_e1_temperatura_alta" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_e1_temperatura_alta" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="31" colspan="6"><div align="left">TEMPERATURA BAJA </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_temperatura_baja" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_temperatura_baja" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_temperatura_baja" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="32" colspan="6"><div align="left">VIBRACIONES</div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_vibraciones" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_vibraciones" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_vibraciones" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="27" colspan="6"><div align="left">PRESIÓN BAROMÉTRICA </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e1_presion_barometrica" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e2_presion_barometrica" value="checkbox">
                          </div></td>
                          <td><div align="center">
                              <input type="checkbox" name="e3_presion_barometrica" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="23" colspan="6"><div align="left"></div></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="32" colspan="13"><div align="center"><strong><u>REVISIÓN POR SISTEMA</u> </strong></div></td>
                          <td height="32">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="center"></div></td>
                          <td height="22"><div align="center">SI</div></td>
                          <td width="78" height="22"><div align="center">NO</div></td>
                          <td colspan="4">&nbsp;</td>
                          <td colspan="4"><div align="center"></div></td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4">                            <p align="left">NERVIOS Y ORG. DE LOS SENTIDOS </p></td>
                          <td width="85" height="48"><div align="center">
                            <input name="rb_rps1" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                            <input name="rb_rps1" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="4"><div align="right">
                            <input type="text" name="rps_nervios">
                          </div></td>
                          <td colspan="4"><label>
                            <div align="center"></div>
                          </label></td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="left">RESPIRATORIO</div></td>
                          <td height="36"><div align="center">
                            <input name="rb_rps2" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                            <input name="rb_rps2" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="4"><div align="right">
                            <input type="text" name="rps_respiratorio">
                          </div></td>
                          <td colspan="4"><div align="center"></div></td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="left">CARDIOVASCULAR</div></td>
                          <td height="36"><div align="center">
                            <input name="rb_rps3" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                            <input name="rb_rps3" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="4"><div align="right">
                            <input type="text" name="rps_cardiovascular">
                          </div></td>
                          <td colspan="4"><div align="center"></div></td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="left">GASTROINTESTINALES</div></td>
                          <td height="36"><div align="center">
                            <input name="rb_rps4" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                            <input name="rb_rps4" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="4"><div align="right">
                            <input type="text" name="rps_gastrointestinales">
                          </div></td>
                          <td colspan="4"><div align="center"></div></td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="left">GENITOURINARIAS</div></td>
                          <td height="36"><div align="center">
                            <input name="rb_rps5" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                            <input name="rb_rps5" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="4"><div align="right">
                            <input type="text" name="rps_genitourinarios">
                          </div></td>
                          <td colspan="4"><div align="center"></div></td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="left">OSTEOMUSCULARES</div></td>
                          <td height="36"><div align="center">
                            <input name="rb_rps6" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                            <input name="rb_rps6" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="4"><div align="right">
                            <input type="text" name="rps_osteomusculares">
                          </div></td>
                          <td colspan="4"><div align="center"></div></td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4">                            <p align="left">T. ENDOCRINOS Y METABÓLICOS </p></td>
                          <td height="52"><div align="center">
                            <input name="rb_rps7" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                            <input name="rb_rps7" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="4"><div align="right">
                            <input type="text" name="rps_endocrinos_metabolicos">
                          </div></td>
                          <td colspan="4"><div align="center"></div></td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="4"><div align="left">PIEL Y FANERA </div></td>
                          <td height="36"><div align="center">
                            <input name="rb_rps8" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                            <input name="rb_rps8" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="4"><div align="right">
                            <input type="text" name="rps_piel_fanera">
                          </div></td>
                          <td colspan="4"><div align="center"></div></td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="24" colspan="15">&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="52" colspan="14"><div align="center"><strong><u>EXAMEN FÍSICO </u></strong></div></td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td width="155"><strong>ORGANO</strong></td>
                          <td width="18"><strong>N</strong></td>
                          <td width="25"><strong>AN</strong></td>
                          <td width="1">&nbsp;</td>
                          <td height="19" colspan="2"><strong>ORGANO</strong></td>
                          <td width="63"><div align="center"><strong>N</strong></div></td>
                          <td width="71"><strong>AN</strong></td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>ABDÓMEN</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef1" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef1" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="20" colspan="2">CABEZA</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef13" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef13" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="20">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>GENITALES EXT. </td>
                          <td height="20"><div align="center">
                              <input name="rb_ef2" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef2" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="20" colspan="2">OJOS</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef14" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef14" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="20">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>HERNIAS</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef3" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef3" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="20" colspan="2">CONJUNTIVA</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef15" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef15" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="20">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>MIEMBRO INFERIOR </td>
                          <td height="20"><div align="center">
                              <input name="rb_ef4" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef4" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="20" colspan="2">NARIZ</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef16" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef16" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="20">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>MIEMBRO SUPERIOR </td>
                          <td height="20"><div align="center">
                              <input name="rb_ef5" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef5" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="20" colspan="2">OROFARINGE</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef17" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef17" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="20">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>COLUMNA</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef6" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef6" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="20" colspan="2">DENTADURA</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef18" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef18" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="20">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>PIEL Y FANEAS </td>
                          <td height="20"><div align="center">
                              <input name="rb_ef7" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef7" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="20" colspan="2">OIDOS</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef19" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef19" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="20">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>NEURÓLOGO</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef8" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef8" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="20" colspan="2">CUELLO</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef20" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef20" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="20">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>REFLEJOS TEND. </td>
                          <td height="20"><div align="center">
                              <input name="rb_ef9" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef9" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="20" colspan="2">TORAX</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef21" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef21" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="20">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>TINNEL</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef10" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef10" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="20" colspan="2">SENOS</td>
                          <td height="20"><div align="center">
                              <input name="rb_ef22" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef22" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="20">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>FHALLEN</td>
                          <td height="29"><div align="center">
                              <input name="rb_ef11" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef11" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="29" colspan="2">RUIDOS RESPIRATORIOS </td>
                          <td height="29"><div align="center">
                              <input name="rb_ef23" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef23" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="29">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>OTROS</td>
                          <td height="24"><div align="center">
                              <input name="rb_ef12" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef12" type="radio" value="radiobutton">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="24" colspan="2">RUIDOS CARDIACOS</td>
                          <td height="24"><div align="center">
                              <input name="rb_ef24" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef24" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="24">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>&nbsp;</td>
                          <td height="26">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td height="26" colspan="2">OTROS</td>
                          <td height="26"><div align="center">
                            <input name="rb_ef25" type="radio" value="radiobutton">
                          </div></td>
                          <td><div align="center">
                              <input name="rb_ef25" type="radio" value="radiobutton">
                          </div></td>
                          <td colspan="2">&nbsp;</td>
                          <td height="26">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td>&nbsp;</td>
                          <td height="29">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td height="29" colspan="6">&nbsp;</td>
                          <td height="29"><div align="center"></div></td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="46" colspan="14"><div align="center"><strong><u>CONCEPTO</u></strong></div></td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="2">Apto sin limitaciones o restricciones para el cargo
                          <label> </label></td>
                          <td><label>
                            <div align="center">
                              <input type="checkbox" name="apto_sin" value="checkbox">
                            </div>
                          </label></td>
                          <td>&nbsp;</td>
                          <td height="30" colspan="6">Apto para trabajo en alturas
                          <input type="checkbox" name="apto_para_trabajo" value="checkbox"></td>
                          <td><div align="center"></div></td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="2">Apto con limitaciones o restricciones para el cargo </td>
                          <td><div align="center">
                            <input type="checkbox" name="apto_con" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="30" colspan="6">Apto para manipulacion de aliementos 
                          <input type="checkbox" name="apto_para_manipulacion" value="checkbox"></td>
                          <td><div align="center"></div></td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="2">Al examen de egreso no hay evidencia de enfermedad profesional
                            <label></label></td>
                          <td><div align="center">
                              <input type="checkbox" name="al_examen" value="checkbox">
                          </div></td>
                          <td>&nbsp;</td>
                          <td height="52" colspan="6">Aplazado-Motivo
                            <label> :
                            <textarea name="aplazado_motivo" cols="30"></textarea>
                            </label></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="30" colspan="2">&nbsp;</td>
                          <td height="30">&nbsp;</td>
                          <td height="30">&nbsp;</td>
                          <td height="52" colspan="6">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td colspan="2">observaciones y recomendaciones </td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td height="52" colspan="6">&nbsp;</td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="52" colspan="10"><label>
                            <textarea name="textarea" cols="70" rows="4"></textarea>
                          </label></td>
                          <td>&nbsp;</td>
                          <td>&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                        <tr>
                          <td height="52" colspan="10"><label></label></td>
                          <td height="52">&nbsp;</td>
                          <td height="52">&nbsp;</td>
                          <td colspan="2">&nbsp;</td>
                          <td>&nbsp;</td>
                        </tr>
                      </table>
                    </div>
                    <div align="center"></div><label></label>
                    <label></label>
                  </FORM>
                  </p>
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